| Certificate Number | 226 | | Date Issued |
| Child Given Name | |
Ellsworth | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Aug 1889 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Elmer |
Elsworth | Father's Surname |
| Father's Occupation | Solicitor | | Father's Nationality |
| Father's Birth Place | Illinois | 26 | Father's Age |
| Mother's Given Name | | Edwards | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |